Methadone alternative needs to be supported

You might say Christmas came early this year for the addiction treatment community. Last Friday, in the final hours of the 109th Congress, our elected representatives in Washington, D.C., approved a measure that more than triples the number of people who can be treated for opiate addiction using the maintenance drug buprenorphine, marketed as Suboxone or Subutex.

Maine Sen. Susan Collins was among a small, bipartisan cadre of senators who sponsored the measure and celebrated its unanimous passage on Friday.

“Maine has one of the highest rates of opioid addiction in the nation,” Collins said in a prepared statement last week. “I am pleased that my colleagues in the Senate recognized that current law does not reach far enough to alleviate the ongoing crisis in our state and has acted to expand access to needed care for a very desperate population.”

That said, it’s important to note that neither Collins nor her congressional colleagues are ultimately responsible for getting this life-saving treatment to the Mainers who need it most. It’s Maine doctors in small-town practices who must step up to that plate, and, to date, they have been less than enthusiastic about opening their doors to the stigmatized ranks of the addicted.

Buprenorphine was approved for use in 2002. Like methadone, buprenorphine satisfies the body’s intense craving without producing much by way of a high. This means – ideally – that addicted people in effective treatment are able to go about the day-to-day business of living productive lives.

Unlike methadone maintenance therapy, though, buprenorphine does not have to be administered in a heavily regulated environment like the nonprofit clinic at Acadia Hospital in Bangor or the smaller, for-profit methadone programs that have sprung up around the state in recent years. People travel many miles to these regional treatment centers to receive their daily dose of methadone, and treatment often becomes the central reality of their lives.

Buprenorphine, however, was approved for use in the context of hometown primary care practices, with a goal of making treatment more convenient, less stigmatizing and more likely to succeed. It’s not effective for everyone, but for some people it’s a big improvement over methadone.

But nothing is simple. Because people with addictions are especially challenging to treat in a general practice, the federal Food and Drug Administration requires doctors to take an eight-hour class and pass a certification exam before they can prescribe buprenorphine. And Congress, citing concerns for patient safety and physician overload, originally capped the number of patients that could be treated in any one practice to 30. Last year, legislators amended the law to allow each physician in a practice to treat 30 people. And last week, they said any certified doctor who has been prescribing buprenorphine for a year or longer can treat as many as 100 people. It remains for President Bush to sign the bill into law, which he is expected to do in January.

Dr. Mark Publicker, medical director of the Mercy Recovery Center in Westbrook, said Tuesday that the latest change in buprenorphine regulation is “extremely important” for Maine, where, he said, an estimated 34,000 people live with an untreated addiction to opiates.

“This will allow us to treat thousands of people who would not otherwise get treatment,” Publicker said.

But to date, only a small percentage of Maine doctors have gotten certified to prescribe buprenorphine. And of the approximately 120 primary care providers and substance abuse specialists who are certified, fewer than half currently provide ongoing buprenorphine maintenance therapy. Some doctors will prescribe the medication short-term to help their patients detox, but then discontinue it. Others are certified but won’t prescribe buprenorphine at all.

According to the Maine Office of Substance Abuse, almost half of our certified doctors won’t allow their names to be listed in the state’s directory because they don’t want their offices overrun with addiction patients. Of those doctors who do prescribe buprenorphine, many are associated with the same regional treatment centers that supply methadone or other substance abuse treatment.

All of which defeats the central advantages of buprenorphine over methadone as a maintenance therapy. It was envisioned as a community-based treatment provided by a far-reaching network of qualified rural doctors. If people with opiate addiction still have to travel long distances to get this medication, if they have to line up for treatment at specialized drug-addiction programs instead of having their condition managed with dignity by their own local doctors, buprenorphine fails to fulfill its promise and Maine doctors fail our drug- addicted citizens.

What a service our rural physicians would perform in our besieged state if they would accept the challenge of treating the addicted in the communities where they live – if they would take the time to get certified, post their names prominently and open their doors wide to those desperate Mainers trying to reclaim their lives. Then Congress’ recent gift would have the chance it deserves to save Maine lives, and caring, committed doctors in small towns throughout the state would truly shine beacons of hope in this dark season.

Please join our weekly conversation about Maine’s substance abuse problem. We welcome stories, comments or questions from all perspectives. Letters may be mailed to Bangor Daily News, P.O. Box 1329, Bangor 04401. Send e-mail contributions to findingafix@bangordailynews.net. Column editor Meg Haskell may be reached at (207) 990-8291 or mhaskell@bangordailynews.net.